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Breastfeeding Nutrition 526. Ginna Wall, RN, MN, IBCLC gwall@u.washington.edu University of Washington Medical Center Lactation Services. University of Washington Medical Center Lactation Services. Nancy Estill, Louise Peterson, Ginna Wall, Christy Shaw, Barb Lautman.

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Breastfeeding Nutrition 526

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BreastfeedingNutrition 526

Ginna Wall, RN, MN, IBCLC

gwall@u.washington.edu

University of Washington Medical Center

Lactation Services


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University of Washington Medical CenterLactation Services

Nancy Estill, Louise Peterson, Ginna Wall, Christy Shaw, Barb Lautman

RNs, International Board Certified Lactation Consultants


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Objectives

  • Describe the function of placental hormones, oxytocin, and prolactin in the breastfeeding process

  • Describe the let down reflex and list factors that may interfere or enhance this reflex

  • Recognize major contraindications to breastfeeding

  • Recognize factors that contribute to successful initiation and maintenance of breastfeeding

  • Describe correct positioning and latch on for successful early breastfeeding


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The Most Important Factors For Good Milk Supply:

  • Prepared mammary epithelium

  • Progesterone withdrawal

  • Maintained plasma prolactin

  • Removal of milk within an undefined interval after birth


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Prolactin

Levels rise in pregnancy


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Prolactin Hormone

  • Helps women respond to stress of perinatal period

  • Suckling is the most effective stimulus for prolactin release

  • Direct stimulation of the nipple is necessary for prolactin release

  • Prolactin levels rise as long as stimulation continues






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Let Down or lactiferous duct Milk Ejection Reflex

  • Effective milk removal depends on the ejection reflex

    • Duct diameter increases 50%


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Milk duct before letdown lactiferous duct


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Milk duct after letdown lactiferous duct


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Early Post-birth Events lactiferous duct

  • Baby crawls to breast

  • Opens and closes hands

  • Massages the breast

  • Hand movements cause as high an oxytocin rise as sucking



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Skin-to-skin contact encourages oxytocin release lactiferous duct

  • Oxytocin:

    • Promotes milk

    • Promotes mothering behaviors

    • Alleviates pain


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Oxytocin in the bloodstream lactiferous duct

  • Released with nipple stimulation

  • Released in surges, lasting about 1-2 minutes

  • Contracts muscle cells

    • Causes uterine contractions, causing involution

    • Causes contractions of the muscle cells surrounding alveoli and ducts in the breast, causing milk “let down” or “milk ejection reflex”


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Oxytocin Effects: Opposite of “Fight or Flight” Response

  • Lowers heart rate

  • Lowers blood pressure

  • Lowers blood cortisol

  • Stimulates endorphins

  • Affects metabolic actions

    • Contracts pyloric sphincter

    • Releases insulin and cholecystokinin


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Oxytocin In The Brain Affects Social Behavior Response

  • Women who have high levels of oxytocin

    • Produce more milk

    • Breastfeed longer

    • Are more tolerant of repetitious, boring tasks

    • Demonstrate more “social” behavior – better listeners

    • Women become more social and retain those traits if they continue breastfeeding


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The Let Down Reflex Response

  • List factors that interfere with this reflex

  • List factors that enhance this reflex


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Cholecystokinin stimulates oxytocin Response

  • Food for mother


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Is it ever ResponseNOT a good idea to breastfeed?

Contraindications to Breastfeeding:

  • Maternal: HIV, HTLV-1, Herpes lesion on the nipple, Some drugs (cocaine, methamphetamine, radioactive drugs)

  • Infant: Galactosemia, PKU (partial breastfeeding may be possible)


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Factors that contribute to successful initiation and maintenance of breastfeeding

  • 1991 WHO/UNICEF: Baby Friendly Hospital Initiative, “Ten steps to successful breastfeeding”

  • Certified 14,500 hospitals in 125 countries

  • 40+ US hospitals

  • In WA State:

    • Evergreen

    • St Mary’s

    • Okanogan

    • Tacoma General

    • And in 2008: UWMC!

    • And Group Health!


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Baby Friendly Hospital: maintenance of breastfeedingWhat are the “Ten Steps?”

  • Have a written breastfeeding policy that is routinely communicated to all health care staff.

  • Train all health care staff in skills necessary to implement this policy.

  • Inform all pregnant women about the benefits and management of breastfeeding.

  • Help mothers initiate breastfeeding within an hour of birth.

  • Show mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants.


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“Ten Steps,” continued… maintenance of breastfeeding

  • Give newborn infants no food or drink other than breastmilk, unless medically indicated.

  • Practice "rooming in" by allowing mothers and infants to remain together 24 hours a day.

  • Encourage breastfeeding on demand.

  • Give no artificial teats, pacifiers, dummies, or soothers to breastfeeding infants.

  • Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or birthing center.


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Does “Baby Friendly” maintenance of breastfeedingMake a Difference?

  • Promotion of Breastfeeding Intervention Trial

  • 30 hospitals, randomized to receive Baby-Friendly training, or continue routine practices

  • 17,000 mother-baby pairs

  • Followed for 1 year


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“PROBIT” Results maintenance of breastfeedingKramer, JAMA, Jan 2001


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Baby-Friendly Hospital Initiative: maintenance of breastfeedingReduction in GI Infections and AllergiesKramer, JAMA, Jan 2001


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“Maternity Care Practices: maintenance of breastfeedingImplications for Breastfeeding”

  • Surveyed 1085 women who intended to breastfeed for more than 2 months

  • Assessed 5 Baby-Friendly practices:

    • Breastfeeding initiation

    • Supplements

    • Rooming-in

    • Breastfeeding on demand

    • Pacifiers

DiGirolamo, Grummer-Strawn, and Fein, BIRTH 28:2, 94, June 2001


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Percentage of women who stopped breastfeeding before 6 weeks, by specific hospital practices

DiGirolamo, BIRTH, June 2001


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Percentage of women who stopped breastfeeding before 6 weeks, by number of Baby-Friendly Hospital Initiative practices they experienced

DiGirolamo, BIRTH, June 2001

% STOPPED

BF

Number of Baby-Friendly Practices Reported


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“BFHI Improves Breastfeeding Initiation Rates in a US Hospital Setting”

  • Boston Medical Center

    • inner-city teaching hospital

    • 1800 births per year

    • 15-bed Level III NICU

    • primarily poor, minority, immigrant families

  • Implemented Baby-Friendly policies over a 3-year period

  • Reviewed 200 randomly selected medical records from each of the 3 years

  • Philipp, PEDIATRICS, Sep 2001


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    BFHI IMPLEMENTATION: Hospital Setting”EFFECTS ON BREASTFEEDING TRENDS

    Philipp, PEDIATRICS, Sep 2001


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    ABCs of Helping Mothers to Breastfeed Hospital Setting”

    • A is for Attachment of baby’s mouth to mother’s breast (“latch”)

    • B is for Breastmilk (transfer of milk from breast to baby, and how to establish a good supply)

    • C is for Confidence (tell her what a good mother she is!)


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    A Good Latch Hospital Setting”

    • Nipple completely disappears

    • Lips are flanged out

    • Angle of baby’s lips is about 120 degrees


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    Latch Scoring Practice Hospital Setting”with video:

    Jane Morton MD: “15 minutes of breastfeeding help”


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    How parents can tell that baby is getting enough Hospital Setting”

    • Stooling and urination patterns

      • Meconium first day (one or more)


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    Stooling and urination patterns Hospital Setting”

    • Transitional stool day 2-4 (usually one or more each day)


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    Stools when milk is "in” Hospital Setting”

    • By day 4: 4 stools each day (not just a stain in the diaper)

    • Frequent bowel movements for the first 4-6 weeks


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    Common Problems Hospital Setting”

    • Sore nipples

    • Engorgement

    • Low milk supply

    • Preterm and “late preterm” infants

    • Questions about drugs

    • Working outside the home

    • Infant sleep, crying, temperament issues

    • Relationships, social isolation


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    Test Weighing Hospital Setting”

    • Use “integrating” digital scale

    • Reweigh promptly in exactly the same way

    • 1 gram = 1 ml milk


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    Double-Pumping Single-Handedly Hospital Setting”



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    Finding Breastfeeding Support Services in the US Hospital Setting”

    breastfeeding.com

    ilca.org

    iblce.org


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